There have been few articles in this journal on the
importance of diagnostic services in primary care.
From the patient’s perspective, quality in primary
care also means that the general practitioner (GP)
has access to accurate and timely laboratory services.
The numbers of tests being ordered by GPs is rising
and nurses are now involved in requesting laboratory
investigations.[1]

Patients assume that laboratory investigations will
be accurate. However, it is unlikely that many patients
know the nature of the test, or the investigation to be
carried out on the sample being taken, or who is
responsible for carrying out the work. Patients are
not infrequently told ‘we shall do some tests and send
them to the lab’. For example, when a blood or urine
sample is taken, the patient is not necessarily told what
specific tests are being requested; and equally important,
patients are not necessarily told what the pathologist
found. Patients may have to assume that ‘no
news is good news’. They may be told that the ‘results’
appear ‘all right’, or that more ‘investigations’ are
needed or perhaps that there is a ‘specific problem’.[2]
None of these terms are helpful in keeping the patient
informed about what is happening to them or in
informing them about the work of the pathologist
who is also involved in their care.

Over the last 100 years, the pattern of disease has
changed dramatically. Improved living standards,
better nutrition, and effective drug and immunisation
therapies have meant a decline in acute infectious
diseases. These have been replaced by chronic conditions
such as cancer, coronary heart disease, strokes,
mental health problems and Alzheimer’s disease. The
result being that many patients have had to learn to
live with chronic and degenerative disease.[3] Additionally,
a great majority of these patients now receive their
health care in the community. Patients with chronic
conditions have many tests to monitor their illness
and guide their treatment and when there is an acute
illness or an acute episode, frequent and complex
investigations and tests are likely to be arranged.
Therefore, for patients the link between pathology
and primary care is extremely important.

Many patients have experienced the complexities
of out-of-hours services in general practice. However,
few will have considered the difficulties surrounding
the reporting of abnormal laboratory test results to
primary care out of hours. The request for investigation
bears the contact details of the referring GP but
not of the patient and deputising services do not
currently have access to patient notes. Staff at the
deputising services, who do not know the patient, may
not appreciate the importance of the abnormal result.
They may not be willing to accept responsibility for a
result that was generated through a request made by
the GP or other appropriate primary care staff member
within normal working hours.[4] While serious
abnormal results that need to be acted upon cannot
always be anticipated, the patient is unlikely to:

• know what investigations are being carried out

• be asked by primary care staff how they could be
contacted out of hours

• be asked by primary care staff to contact the
deputising service directly to ascertain the result.

It is clearly essential that when an abnormal result is
identified out of hours and treatment or further
investigation is required, that contact can be made
with the patient. However, consideration needs to be
given to confidentiality and data protection, particularly
if the patient’s telephone number were to be
included on the request slip. The patient would need
to agree to have their telephone number on the slip.
Beastall suggests that in future all laboratories will
need to have an agreement with their local primary
care trusts of the detailed procedures for the reporting
of abnormal results out of hours to protect patients.
However, the problem of speedy information out of
hours from the laboratory to the deputising services
may eventually be solved when the electronic patient
record is operational.

Doctors and now nurses need access to accurate and
high quality laboratory services. Requests to laboratory
services for investigations always come from
professional staff. Patient centred care in the
community could involve the patient or their carer requesting an investigation. It could well be convenient
and appropriate for ‘expert’ patients involved
in the management of their own chronic condition to
request specific investigations from the laboratory.
The Expert Patient Programme sets out a vision of a
programme to increase the capacity of patients with
chronic illness to access health and social care services
effectively, to increase their knowledge about their
condition and its treatments, and to help them spend
fewer days in hospital and doctors consulting rooms.[5]
A further aspect of the informed or expert patient is
that patients with, for example, HIV or cancer need to
know that their tissue samples are kept and that they
can request further tests to be done on them, as tests or
treatments that are dependent on newly discovered or
developed histological, immunological or biochemical
factors come along. Patients need this information
to protect their own interests.[2] The expert patient
programme gives control to the patient, and in addition
there is evidence that expert patients probably
receive fewer and higher quality consultations that are
satisfying both to doctor and patient, and save GP and
patient time.[6]

Quality also involves educating the public about
pathological investigations as well as informing individual
patients about the nature of the investigation.
The patient may be told what the investigation is for,
but the tests or investigations themselves are seldom
described or explained to the patient. There are several
possible explanations for this including paternalism or
the belief that technical matters need not be talked
about or simply that that ‘the patient would not
understand’. In addition, there is now the very real
problem of shortage of consultation time in general
practice. Nurses may not have sufficient knowledge to
discuss technical matters with the patient, and pathologists
have not necessarily provided the appropriate
information for primary care staff to give to patients.
The Royal College of Pathologists has produced a
variety of useful information leaflets for patients and
the public, including an excellent recent one on
allergies and plants to avoid growing in a low-allergen
garden.[7] Most of this information can be accessed
electronically and could be given to patients in consultations
or displayed on practice noticeboards.

Patients and those looking after them in primary
care need access to quality pathology services. As
practices devolve out-of-hours work to deputising
services, reliable systems need to be established to
ensure that the patient can be alerted when an abnormal
result requires immediate attention. Doctors and
nurses have a professional obligation to explain to
patients the nature of investigations to be carried out
and the work of the pathology services.